Provider Demographics
NPI:1871675637
Name:POLICH, MICHAEL ALAN (NP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALAN
Last Name:POLICH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-2491
Mailing Address - Country:US
Mailing Address - Phone:219-696-4101
Mailing Address - Fax:
Practice Address - Street 1:792 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:IN
Practice Address - Zip Code:46356-2491
Practice Address - Country:US
Practice Address - Phone:219-696-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001158A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200324200Medicaid
ILK46894Medicare UPIN
ILK46893Medicare UPIN
IN200324200Medicaid
IN407750GMedicare PIN
IN185640EMedicare ID - Type Unspecified